HomeMy Public PortalAbout5129 SULTANA AVE_Electrical__ WORKER S'COMPENSATION DECLARATION 76 E-806G (180)
CE-806G APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELEST BUILDING AND SAFETY
insure or a certificate of Workers'Compensation Insurance,or /
a certified copy thereof(Sec 3800,Lab C)
FOR APPLICANT TO FILL INJOB
Policy No Company EACH NO FEE ADDRESS Jia �9 SIVA '
❑ , New Residential Bldgs &Pools _
Certified copy u hereby furnished 1 &2 Family,Scl Ft S — S LOCALITY Cl-r) �L CST
0 Certified copy n filed with the county building inspection Multi family Sit m CROSS ST 5j F2 E/✓ 0 /
department Residential Swimming Pools OWNER OR
Date Applicant �qi FIRM NAME 45 �cl l tj �P 6A.eclq
DD Outlets Rec,Llght Sw _ MAIL
CERTIFICATE OF EXEMPTION FROM WORKERS' —first 20 ADDRES .,"
COMPENSATION INSURANCE Total No — Additional CITU E ,/ 7-,Y,T a I N0
i PLAN CHECK d
(This section need net be,com feted If th0 work Involved APPLICANT) 8
by the permit a for one hundred dollere ($100) or less) Lighting Fixtures First 20 ADDRESS V
Total No Additional ¢O
Tel No
1 permit
that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITU F
permit n wised, I shall not employ any person m any manner � PIE RM1T
so as to become subject to the Workers' Compensation Laws Range_Heater D W _ _ APPLICANT w"
�'gyp' m� e{ [7 Oven _ Dryer_W M _ ADDRESS �Z
to�-/9-ffJ Applicant /LO 1D21�._) Top FAU _WH
Fo
Hood _ Fan _Other_ CITY YZ
TeI No
ICE TO APPLICANT If, after making this CertiFlcate of Dup _Room Av Cond ' NSE Oemption, you should become subject to the Workers REG NUMBER Cleompensation provisions of the Labor Code, you must forth power Apparatus& Large Appliances DISTRICT NO PROCE SED BY
with comply with such provisions or this permit shag be
eemed revoked Size&Type HP,KW, KVA or KVA !- aY
Up to 1 Incl FINAL J �7
Over 1 to 10 Incl DATE G T —�/ VALIDATION
LICENSED CONTRACTORS DECLARATION Over 10 to 60 Incl
hereby affvm that 1 am licensed under provisions of Chapter Over 60 to 100 Inc FINAL
(commencing with Section 7000) of Division 3 of the Busl BY Over 100 -�
en and Professions Code, and my license ts in full force and
Ifect Services
icense Number— Lic Class 1 0 200 Amp Under 600 V
201-1000 Amp'Under 600 V
ontfactor Date Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole& Appurtenances '
hereby affirm that 1 am exempt from the Contractor's Sign with One Branch Circuit,
icense Law for the following resson (Section 7031 5, Busi Additional Sign Branch Circuits Y5 of 2 8 A
I as owner of the
less and Professions Code) .
Gs& Conductors
property well do the work and the Other (Seeee Complete Fee Schedule)—
atructure is not intended or offered for ante (Section ,
7044, Business and Professions Code) ,2;e ie 2 2 0 0
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency e e e 2 2 0 O P! ,
r the performance of the work for which this permit is :PERMIT FEE (Sub-Total) t '
sued (Sec 3097 Cry C) 0 5) 9-8 1
ender s Name PLAN CHECKING FEE (One Fourth Permit Fee)
nder's Addressi I
PERMIT ISSUING FEE
1 _
certify that 1 have read this application and state that the TOTAL FEE 1
ve information n correct I agree to comply with a0 County '
dmances and State laws regulating Electrical wiring and
reby authonze representatives of this County to enter upon
e above mentioned property for wpection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
s S—/9— ?/ t
igns tura of perm1wee Date - 1 '
COUNTY OF IAS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0910070014
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
LEGAL ID FEES PAID BUILDING ADDRESS
BK 74 PG 45 PC 1 5129 SULTANA AV
FEE DESCRIPTION QUANTITY GUM AMOUNT TEMP CA 917803048
(ASSESSOR INFORMATION NUMBER NEAREST CROSS STREET PENTLAND
15388-019-034 Al PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 596 GRID H5 LOCALITY TEMPLE CITY, Cl
G1 OUTLETS-LGT,SW,RECP 2 00 OUT 3 90 I
1TENANT IG2 LIGHTING FIXTURES 1 00 LOT 1 95 TISSUED ON PROCESSED BY PIAN BY EXPIRES ON I
1 TOTAL FEES 33 60 110/07/09 SR 10/07/10
OWNER TEL NO IF NAL DATE F7IljJAAAIII,BY CODE
LOU, SHARON T (626) 215-6677- 1 1(�'� �J
6743 LONGMONT AVE �/�l 11
1SAN GABRIEL CA 91775 DESCRIPTION OF WORK
ELECTRICAL FOR NEW BATHROOM
(APPLICANT TEL NO
THEINS/RIGHT ANGLE BUILDER (626) 272-6057-
18509 ROANOKE RD SPECIAL CONDITIONS
SAN GABRIEL CA 91775
1(CONTRACTOR TEL NO (APPROVALS DATE INSPECTOR SIGNATURE
RIGHT ANGLE BUILDERS (626) 272-6057- I
18509 RAONOKE ROAD LIC NO (TEMPORARY POWER POLE
ISAN GABRIEL, CA 91775 926171 B
(UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER TEL NO OVER GROUND 1
LIC NO ROUGHCONDUIT
ROUGHWIRING `(u'
MAIN WATER LINE
PLASTIC Y/N METAL Y/N I 1
(UTILITY COMPANY NOTIFIED(
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IREPORT IO DPR265 ROUTE TO BS0508 _I
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COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0908200001 '
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
ILEGAL ID FEES PAID BUILDING ADDRESS '
IBR 74 PO 45 PC 1 5129 SULTANA AV 1
( 7803048
ASSESSOR INFORMATION NUMBER ]FEE DESCRIPTION QUANTITY UIX4 AMOUNT BEST MOSSMOSS PENTLAND '
5388-019-034 IAT PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 596 GRID H5 LOCALITY TEMPLE CITY C
]G1 OUTLETS-LOT,SW,RECP 4 00 OUT 7 80
TENANT G2 LIGHTING FIXTURES 1 00 LGT 1 95 ISSUED ON PROCESSED BY PLAN BY EXPIRES ON I
TOTAL FEES 37 50 08/20/09 SR 08/20/10 I
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OWNER TEL NO Fr DATE P CODE ]
LAO SHARON T (626) 215-6677-
]6]43 LONGMONT AVE
ISAN GABRIRL CA 91775 D SCR I OF FORX
1 14 OUTLETS AND 1 LIGHT FIXTORE
APPLICANT TEL NO 1 1
IWONG (310) 430-5209-
5131 SULTANA AVE SPECIAL CONDITIONS
TEMPLE CITY CA 91780
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CONTRACTOR TEL NO APPROVALS DATE INSPECTOR SIGNATURE
RIGHT ANGLE BUILDERS (626) 272-6057- 1
9509 RAONOKE ROAD LIC NO ]TEMPORARY POWER POLE
SAN GABRIEL, CA 91775 924171 H
I UNDERGROUND CONDUIT I
]ARCHITECT OR ENGINEER TEL NO UFER GROUND
LSC NO ROUGH CONDUIT
ROUGH WIRING
MAIN WATER LINE
(PLASTIC Y/N METAL Y/N
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I UTILITY COMPANY NOTIFISDI I 1
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REPORT ID DPR265 ROUTE TO B90508 1 1
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